Healthcare Provider Details

I. General information

NPI: 1205855145
Provider Name (Legal Business Name): MARC LUTHER WILCOX MS CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 CENTRAL AVE W123 THOMPSON HALL
FREDONIA NY
14063-1127
US

IV. Provider business mailing address

280 CENTRAL AVE W123 THOMPSON HALL
FREDONIA NY
14063-1127
US

V. Phone/Fax

Practice location:
  • Phone: 716-673-3203
  • Fax:
Mailing address:
  • Phone: 716-673-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number001310-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: